It cannot be known for certain where the mate was standing when he fell overboard. Reportedly, he was somewhere between the bollard and the side shell ladder. It is not known if he was walking towards the bow, following other crew members, or was still monitoring the barge's progress when he fell. The cause of his fall is equally uncertain. Although the partially rusty deck plates created, in general, a non-slippery surface, the deck was moist with dew at the time of the accident, and there were likely some slippery patches. According to one account, the mate fell overboard astern of the air vent pipe, which suggests that he had not attempted to pass by the pipe. However, immediately after the mate fell, another crew member climbed down the side ladder, approximately five metres ahead of the pipe, to assist the mate. Notwithstanding the above ambiguities, there are several safety issues associated with the barge and the equipment: location of safety lines; obstacles on walkway; and other factors.Analysis It cannot be known for certain where the mate was standing when he fell overboard. Reportedly, he was somewhere between the bollard and the side shell ladder. It is not known if he was walking towards the bow, following other crew members, or was still monitoring the barge's progress when he fell. The cause of his fall is equally uncertain. Although the partially rusty deck plates created, in general, a non-slippery surface, the deck was moist with dew at the time of the accident, and there were likely some slippery patches. According to one account, the mate fell overboard astern of the air vent pipe, which suggests that he had not attempted to pass by the pipe. However, immediately after the mate fell, another crew member climbed down the side ladder, approximately five metres ahead of the pipe, to assist the mate. Notwithstanding the above ambiguities, there are several safety issues associated with the barge and the equipment: location of safety lines; obstacles on walkway; and other factors. Location of the Safety Lines The walkway safety lines on the JUNEAU follow the same design and location (60 cm inboard of the edge) as those on the chip barges. For protection against falling overboard, a person must hold on to the line continuously while using the walkway. On the chip barges, the safety lines were attached__inboard of the edge of the deck__to pre-existing deck box stiffeners. The JUNEAU does not have such stiffeners, and neither the stanchions nor the lines were attached to any existing fixtures on the barge. When these safety lines were (fairly recently) installed, there was no pre-existing structure influencing their location, and they could have been installed in the best possible location__at the edge of the barge__thus guarding the walkway on the outside. The sister barge of the JUNEAUis fitted with a bulwark along the side, a safer method of guarding the edge of the deck. Obstacles on Walkway The entire deck of the barge was used for loading rail cars. The nature of the load precluded the installation of any large fixtures within the loading area. The only available surfaces on which to place the bollards, manholes, cleats, vents, etc., without decreasing the loading space, was the 60 cm strip of the deck at the sides of the barge. The owners of the barge made use of the two strips, placing there all the auxiliary features. It was logical to place the bollards at the edge of the barge. While the manholes, cleats, handholds and other low-profile protrusions are obstacles, a trained seaman could easily pass by them. However, the 41 cm diameter vents in the 60 cm wide walkway were not placed with full regard to the safety of personnel, though handholds had been installed on the top of each vent. A person passing by the vent uses both hands to hold onto the bars on top of the vent. While passing a vent, a person's centre of gravity briefly passes over the side of the barge; this occurs while the only available foothold is the 19 cm wide, uneven surface between the body of the vent and the edge of the deck. It is possible for a physically fit person, with only one hand free, to pass the vent while grasping the bars with only one hand. However, such a manoeuvre is unsafe__especially when the deck is wet and footing may be easily lost. Other Factors The mate who fell from the JUNEAU was recovered without the hand-held VHF radio in his pocket. It is not known however, if at the time of falling, he carried it or had it in the pocket of his coveralls. One glove, possibly his, was recovered from the water near the site of the accident. Attachment of the VHF radio to the mate's coverall or to a waist belt attachment would have left both his hands free to hold on to the safety line and, when passing around the vent pipe, to grab the handholds on the vents. The severe injuries to the torso were caused by crushing between the side of the barge and the dolphin. However, the head injury was most probably caused when the mate, falling over the side, hit either the dolphin or the barge. The wearing of a hard hat (as supplied by the employer) mayminimize head injuries. The lack of dedicated lighting made sighting the deck fixtures difficult and, consequently, would have made passage across the deck__over and around the deck fixtures__more difficult to execute safely. The working conditions on board the barge JUNEAU, comprising a narrow and inadequately protected walkway on its side, the lack of lighting, obstructions and protrusions located within the walkway, and the dew-covered surface of the deck, are factors conducive to an accident. Safety equipment such as a hard hat and headlamp were not used; and the non-strapping of the radio to the coverall exposed the deckhand to higher-than-normal risk and reduced his chances of survival in the accident.Findings as to Causes and Contributing Factors The working conditions on board the barge JUNEAU, comprising a narrow and inadequately protected walkway on its side, the lack of lighting, obstructions and protrusions located within the walkway, and the dew-covered surface of the deck, are factors conducive to an accident. Safety equipment such as a hard hat and headlamp were not used; and the non-strapping of the radio to the coverall exposed the deckhand to higher-than-normal risk and reduced his chances of survival in the accident. Safety Action Action Taken As a result of this occurrence, Seaspan International Ltd. carried out the following modifications to the barge JUNEAU: fuel and water vents were capped at deck level; containment berms around these vents were removed; additional handhold was installed on the top of the ballast vent; and vent lid dogs were removed.